Can Pessaries “Out-sex” Surgery? A Thoughtful Approach to Incontinence and Prolapse

byDr. Shelley S. Binkley, MDonApril 30, 2009

The Breach in the Dam

Do you have incontinence or prolapse? One of the fundamental contributors to prolapse/incontinence is an increase in the size of the genital hiatus. Did you know you can decrease the size of your genital hiatus by 50% without surgery? If you don’t know what your genital hiatus is, it’s an approximate quantification of pelvic muscle function by measuring the distance between the urethra and the anal opening. The genial hiatus (i.e. the muscles surrounding and interweaving the vagina, urethra, and rectum) is essential for normal sexual, bladder, and bowel function and you can learn more about in my post The Genital Hiatus: What It is and Why You Should Care and here (ACOG patient education brochure on prolapse).

Incontinence of urine, gas, and stool affect half of all women at some point in their lives, and is especially common after pregnancy, whether delivery occurs by vaginal birth or c-section. C-section does not prevent incontinence.

An article published in Obstetrics and Gynecology looked at pessary use in women 90 women with incontinence and found a 20% reduction in the size of the genital hiatus in just two weeks! This is really exciting news and I think it should have made the New England Journal of Medicine (or at least Good Morning America…a scroll-by on CNN?). After just two weeks of daytime use, the women wearing a pessary decreased their genital hiatus from an average of nearly 5 cm to about 4 cm, a twenty percent reduction!

In fact, several studies over the past few years have indicated prolapse and incontinence are dynamic conditions dramatically impacted by factors within a person’s control: weight, exercise (Kegels), smoking status, and other factors.

There have been two approaches to incontinence: surgery and pessaries. Surgery has been the predominant approach because IMHO (in my humble opinion), that’s where the money is: incontinence surgery earns income for medical device companies, hospitals, and doctors. In comparison pessaries are cheap.

Why We Lack Data on Pessaries

Pessaries don’t make the news because 1) they aren’t “sexy” like “surgery”; 2) they aren’t a “quick fix”; and 3) they are cheap. The only entities who earn income off the pessary are the physician who does the fitting and the pessary company–pessaries cost about $40-60 (an office visit for a pessary fitting costs a tiny fraction–$100-$250 depending on what is addressed and the duration of the visit–of what surgery pays; a sling surgery pays 10-20X that depending on how complex the reconstructive surgery is.)

Little medical research has been devoted to the study of pessaries versus surgery for incontinence and there have been zero large randomized controlled trials comparing pessary use with surgery. For example, a search of articles published since 2000 in Obstetrics and Gynecology using the term “pessary” returns about 10 actual related results; while a search with the terms “incontince and surgery” yields about 5200 related articles. That’s just sad.

As a physician, if I don’t have the clinical and scientific data, I cannot inform patients well. Treatment of incontinence/prolapse costs over 80 billion dollars annually; why haven’t the NIH and other research funding agencies supported more pessary research??? For example, why don’t we have larger numbers on how pessary vs. surgery affects something measurable like the genital hiatus?

Why To Do KegelsEven if You’re Sold on Surgery

Reveal latent incontinence

Improve pelvic blood flow–will aid healing from any surgery

Improve neuromuscular function

Even if you’re considering surgery for incontinence/prolapse you will benefit from Kegels. Pre-operative Kegels for 10 weeks before surgery will improve your surgical outcome because you will improve the blood flow to all pelvic structures, muscle strength, and neuromuscular function of the pelvic muscles.

Kegeling with a Pessary or Weight

Kegels with a pessary, vaginal weights, or other feedback device such as an Athena, will make your Kegels more effective in a shorter amount of time. The use of these devices provides “resistance” which, as with any muscle training, makes it more effective faster. Wearing a pessary during the day will cause you to do Kegels in an isotonic fashion, unconsciously (to keep the pessary in place). This is probably the mechanism by which wearing a pessary decreases the size of the genital hiatus.

If you have prolapse, sometimes corrective surgery can unmask incontinence that was previously masked by a kinking of the urethra due to the prolapse. Using a pessary pre-operatively can diagnose if you have incontinence that will need to be addressed at your surgery, in addition to the prolapse repair.

If you want to use a pessary, a fitting takes 10 or 15 minutes. Pessaries are very easy to insert, and come in all shapes and sizes.

How to Kegel and How Many

To Kegel, contract the muscles inside the vagina as though you’re trying to stop the flow of urine. You don’t want to do Kegels during urination because it can “confuse” your bladder. Make sure your bladder is empty when doing Kegels.

Try to hold each muscle contraction for 3-5 seconds.

Do ten sets of ten per day for six to twelve weeks, then as needed or desired.

I am always so happy to see continuing education for women in regards to prolapse issues. There are so many problems that women face with the different types of prolapse and it is such a hush-hush scenario most of the time.
A book I have recently written about pelvic organ prolapse also addresses the many faceted issues of prolapse; I feel so strongly that all women should be aware of this condition so when they start to have symptoms, whether with bladder leakage or any of the many other symptoms like fecal incontinence, pain, or sexual dysfunction, they are aware of what may be occurring and seek help before the condition progresses to a stage needing radical treatment. The title of my book is
“Pelvic Organ Prolapse, The Silent Epidemic”
and information is available at the website below. I’d be very happy to share my views on this topic with anyone interested.

Hi Sherrie,
Thank you so much for writing a book on POP (pelvic organ prolapse). I would love to have a great resource to which to refer my patients. There is very little information out there for women on POP. The more people write about this issue, the more awareness will be raised and women can learn, not only how to treat POP non-invasively, but to prevent it. Thank you so much for your comment. I can’t wait to read your book!
–Shelley

My mother, 86, asked me to check into pessaries. Over the last few years, she is becoming ‘dribbly’ incontinent. She visited an urologist that checked and found nothing out of the ordinary. She had tried several meds over the last few years and says she doesn’t like the side-effects. After reading the article, it seems to me that she may benefit from exercise first; she has become more and more sedentary in her lifestyle. Is there a device other than a pessary that could provide additional muscle exercise in the pelvic floor.

@Jeff Thank you for reading and commenting. Other devices to assist with Kegels are the Athena and various weighted vaginal cones. These can be purchased on-line. The Athena has a pressure sensor in it to relay feedback to the individual re: strength of their kegels. A pessary would probably be less expensive than either the Athena or the weighted vaginal cones. Here are some options for purchasing either the Athena or weighted vaginal cones. http://www.athenaft.com/ and http://www.vaginalweights.org/incontinence_products.html

Thank you for this article. I’m seeing the urogynocologist Monday and this has been immensely helpful to know what I want to try, as well as giving me valuable information about pessaries. Before reading this I didn’t really want to try one, now I think that should be the first step.

This is a very interesting website and lots of good information. I am a physical therapist specializing in womens health – primarily urinary/fecal incontinence, prolapse, pelvic pain. I do disagree with your description of how to do Kegels – trying to do 10 sets of 10 reps is way to much exercise for the pelvic floor muscles, especially since these muscles usually weak and that is one of the reasons for incontinence. Also, the endurance training for these muscles has been shown very important, having women progress to 8-10 second contract/relax for 3+ sets of 10. The key factor though is making sure women are doing them correctly, not holding their breath, not using othe muscle groups instead of the pelvic floor muscles. There are good studies that have shown verbal instruction is not sufficient for women to learn how to exercise their pelvic floor muscles. Many of my patients have told me that they were “told to do the exercises, but not taught.” I would highly recommend physicians and health care practitioners not assume by verbal instruction that women know how to do these exercises – physical therapists have specialized training in evaluation of the pelvic floor/abdominal muslces, in teaching these exercises and in progressing patients through treatment including a home exercise program.

When my doctor suggested the use of a pessary I felt just a little bit squeamish. Silly, because I used a diaphragm before my first baby came via low forceps delivery. After that low forceps delivery (following a 46 hours delivery, baby spent a lot of time int he birth canal and was very cone headed afterward with swollen spots on her face from the forceps that lasted about one month) the muscles supporting my bladder were damaged and I could no longer hold a diaphragm in place.
Thank you so much for your post on this subject. The last thing we want as women is to no longer feel like we are attractive and appealing. But, not coping with this problem only serves to make us feel like we are less.
I know other women are struggling with this, but somehow we do not dare to talk about it at book club or other places where women meet.
I know other women struggle. I had friends say, “my friend has this problem…” Only to later hear they had a hyster for prolapse…
Now I just need to learn about what kind of pessary to try. I think I am going to be a bit more willing to talk to my Dr. I am going to ask to see the pessary tray during my visit. I want to talk to my Dr. about the benefits of each type.
Thank you for the information!

Is it possible that a pessary can actually ‘cure’ a uterine prolapse, or at least reverse it enough to not need surgery? I am 56, post-menopausal and went in about two years ago for a prolapsed uterus. It turned out I have both a cystocele and a rectocele as well. I was reluctant to have the recommended surgery so used a pessary for almost 2 years. Finally the leakage got so bad that I gave in and agreed to the surgery, which is scheduled for next week. However, my doctor removed the pessary a month ago in preparation for the surgery and I have not had a recurrence of the uterine prolapse–it seems to be back to where it was before I started having problems. I do realize the cystocelee problem is probably being masked by some kinking.
This leaves me even more reluctant to do this. I’m pretty sure my doctor is going to want me to go through with it anyway. Any
suggestions?

Hi C, Yes, a pessary can certainly reduce uterine or vaginal prolapse enough to make it less symptomatic or not symptomatic at all. The reason the urine leakage may have gotten worse when the pessary was removed, is that by reducing the prolapse you un-kink a presumably kinked urethra. The factors that caused the pelvic prolapse in the first place can also cause a “funnel” urethra. This is a urethra in which the internal urethral sphincter is so relaxed it it non-functional. The urethra has 2 sphincter muscles, one at the junction at the bladder and the urethra (the internal urethral meatus), and the other where the urethra opens to the outside (the external urethral meatus). With a funnel urethra the internal sphincter is so slack, the urethra becomes funnel shaped, rather than tube-shaped. Sometimes a sling will be placed to “cure” the funnel urethra. Placing a sling partially obstructs the too-relaxed urethra, thus helping it to close better and provide continence. It usually works, but slings are not without complications and do have a three year failure rate of 15%. The ten year failure rate is not as well known, but may be fairly high. Thank you for reading the blog and sharing your information with other readers. Let me know if I can answer any other questions. -SB

Yes, you can use a muscle stimulation insert and/or weighted vaginal cones with a pessary in place, if you can fit all that in there. The difficult thing could be fitting all the items in at the same time. Instead, if you are comfortable with removing and reinserting your pessary, I’d recommend removing the pessary while you are using the pressure-sensing insert or weighted vaginal cones, then replacing the pessary when you are not using it. Thank you for reading the blog and for sharing your information, which I know will help other women. Please let me know if you have any additional questions or comments. -SB

I had read this a few weeks ago and was just re-reading it. I was just fitted for a pessary yesterday and hope to be able to reverse my prolapse. This article is very encouraging. I could feel the pressure after doing squats and exercising so I am looking forward to allieviating that.
Thanks,
Julie

Hi L,
The pessary supports the organs but the looseness can only be corrected by Kegel exercises or surgery. Prolapse surgery can have a 30% or greater failure rate over the long term (5 years or more). Consistent Kegels reduce failure rates and improve long term outcomes.
Thank you for reading the blog and commenting.
-Dr. B

Hi Shelley,
I did not have intercourse for about 40 years…..now I have a lover and also a pessary for a dropped blader, which by the way is very comfortable, I don’t feel it at all. The opening of my vagina is now smaller then 40 years ago, I read it’s normal to atrophy if not used! He is very well “equipped” so cannot penetrate, would removing the pessary helps? As per my Dr. instructions I don’t remove the pessary but see him every 6 months, he removes it, clean it etc. now for almost 2 years. Thanks

Hi Jane,
Thank you for reading the blog and sharing your experience. I always encourage patients to be able to remove, clean and reinsert their own pessaries, unless they are physically unable to do so.
-Dr. B

will my partner/spouse feel the pessary during intercourse and will it hurt either one of us using it during intercourse?do we ever take it out?and how often do they need to be replaced?
i have be given two choices,1)surgery which i have been toled that it’s a 50/50 chance it will work.2)the pessary of course until the decission is final i have been given exercises to do.thank you for your information.

Exercises may relieve some or all of the symptoms. If you do have surgery you may get a better result having exercised beforehand. I’d continue to do them as much as possible.
Thank you for reading the blog and commenting.

I have a grade 3-4 cystocele and nothing else. I had an urodynamics test that came out good. I’m in the process of trying a pessary— how do you decide whether to continue the pessary or get the bladder sling surgery? I keep reading horror stories about the post op pain that you can get. I am 60,,,I hate to put off the surgery if it would work better if done earlier. I go back and forth with the attempted decision! thanks,,,,

This is a great website. I came upon it looking for information about anxiety/perimenapuase because I am 41 and all of a sudden feeling anxiety in my chest for no reason and wondering if this is what i have. Anyway i found this topic and i relate because i have POP. I have had it since 2007 after the birth of my first daughter. The pessary has been a huge help. I considered surgery but the pessary works so well, i hate to put myself through it..especially after I’ve just read about the mesh recalls.

Ive been reading this web site and I’m very interested. I too am considering the use of a pessary. Is it really true that using a pessary can strengthen the genital hiatus. How dose it do this by just having it in place? Because if that works it would be wonderful. Ive done kegels till I’m tired of doing them. My prolapse is mild but it still bugs me. I can feel it. ( the small bulge ). And my Dr. has suggested that I try a pessary. I think I will give it a try.

A pessary exerts pressure on the muscles and nerves of the pelvis. In doing so, it stimulates the muscles to contract a bit. You may not even be aware of this. This can increase the basal muscle tone. It’s even more effective to do Kegels with a pessary in place — like working out with weights vs. without weights. You improve muscle mass more effectively by working out with resistance or weights.

Shelley,
I was fitted with a pessary and wore it for about 3 hours. It was so uncomfortable it made me sick to my stomach and I have a high pain tolerance. It has been out now for about 3 hours and I still feel swollen and uncomfortable. It came out when I had a bowel movement.
Is this normal for first time users?
Thank you for your help.

I’ve been in physical therapy for a rectocele for two months (which I believe was caused by the antibiotic levaquin…I developed elbow tendonitis as well). My muscle strength pre-therapy was a 4 out of a 5 and I improved significantly while in PT but the rectocele has worsened. PT said due to ligament laxity (I believe the ligaments were affected by levaquin). Would a pessary help in my case? Is there anything that can be done with ligaments? Thanks.

Levaquin is an anti-biotic. It should not cause a rectocele. If you had diarrhea, a side effect of some antibiotics, that may have caused a latent rectocele to become symptomatic. Physical therapy and a pessary are excellent, effective, low-cost choices for treating a rectocele.

I was diagnosed with both cystocele and a rectocele which has worsened since a recent hysterectomy. I would like to try a pessary before having surgery, but they tried all of the samples could not find one that fit… not even well enough to take it home and try for awhile. The Dr. recommends surgery. After reading your article, I’m wondering if I should still try one that “almost” fits, with hopes that necessary muscles will be strengthened by wearing it? I’m healing slowly from the hysterectomy and had radiation. For this reason I’m concerned about complications and would really like to avoid surgery.

hi … im only 19 years old… I had a handsome baby boy! It was a vaginal delivery no stitches at all.
but the other day i was cleaning myself and I felt something there like a ball coming out, i got veryyy scared i started crying after seeing in the mirror something was there…
that day i called and went to see a doctor he said it was prolapse and that it wasnt so bad but he told me to call the gynecologist and make an earlier appointment because the appointment is on sept 28 I CANNOT WAIT THAT LONG!!
i called and the nurse didnt wanna give me an earlier appointment im so scared, depressed, this is awful, i havent had intercourse yet because im afraid something would happen especially because i havent seen a gynecologist yet to tell me how bad this is or what kind of prolapse it is… I KNOW NOTHING ABOUT IT THANKS TO HIM… and I really hope it doesnt get worse!!
the other doctor just told me not push or lift heavy things, not to stand for long periods of time..
this isnt life.. i rlly miss being just me and being normal
and ive been reading about surgery, pessary and all that and im so scared of surgery i rllyy dont want that!! and the pessary i dont know im also afraid… i just want to have a normal sex life with my partner ….. and im afraid i wont be able to do so anymore…
please anyone using a pessary?? whats it like! can you have intercourse with it and stilll sensation????? or if it hurts!!!

Hi: I had a pessary inserted about 2 years ago and it has changed my life. I had pressure all the time in the vaginal and rectum area and since having the pessary I am good to go. I cannot remove my pessary myself and do have to go to my urogyno every 4 months to have it cleaned. I also use a vaginal douche once a week to make sure it is kept clean.

My doctor recommended it and I hesitated thinking surgery would be the only way to fix it but I was wrong. My doctor was well informed on pessaries and he also pointed out the risks and sometime failures of surgery. I am thankful I have a doctor who isn’t in it for the money and really cares about his patient. My only worry if there is one, is that can having a pessary in place in the vagina for years, could it cause any damage to the bladder or related problems.

I was fitted with a pessary yesterday. I am very encouraged to find that over time it can diminish cystocele POP. How can you tell if your pessary really fits? Sometimes I don’t feel it, sometimes I think I do. Sometimes I think I’m just imagining feeling it! How long does it usually take to become comfortable with a pessary or determine that it doesn’t fit? Also, getting it in and taking it out was difficult and involved some pulling. I’m a little nervous I will do myself harm when I have to remove it. Is that possible? Any suggestions?

Usually with a good fit you won’t feel the pessary most of the time. You may want to experience with two or three different sizes to see which one works best for you. You won’t hurt yourself when removing it, just make sure your finger nails are not too long.

Yes, I read that you cam have sexual intercourse, while having the pessary inserted. But, I am a new realtionship,we have not had sex yet. He is very experienced….Will he be able to tell if I have one inserted???? PLEASE HELP!!!!!!

I had none of the common reactions to Levaquin, like diarrhea. This antibiotic has a black box warning about tendinitis, tendon rupture, and connective tissue problems. It also can cause muscle tissue to break down – but lucky for me, the test results showed that had not started. The doctor instructed me to never take it again unless it was life or death situation.

Just one month prior to going on the antibiotic, I had my annual exam and nothing was out of order. He was surprised when the issue started – I have none of the normal characteristics associated with these problem – and he sent me to a specialist who recommended surgery right off the bat. So I went for a second opinion – who diagnosed entercele in addition to rectocele…both with atypical presentation due to location of each.

I have tried two pessaries – neither worked – they always shifted from horizontal to vertical. So the specialist I was seeing recommended PT (which I was already in) until I wouldn’t help any more. I can’t imagine that there aren’t any other pessaries I could try – I would like to be able to wear one since I would feel more comfortable and that would make the exercises more productive. Do you know of a clearinghouse with information of specialists by state (ones that have been reported based on patient input)?

I have now graduated to a Estring from the pessary and happy to say that other than I have a lot of difficulty removing it ( I really have tried) it has been the perfect remedy for my prolapse and vaginal dryness. Must softer and pliable than the pessary it has worked for a year with little problems and no discomfort at all….Hope this helps..Kind regards, M.j.

I was so happy to find this blog info on pessaries since I had one inserted today for bladder prolapse. The first one the Doctor tried was too big and hurt so he tried a smaller size and had me walk around and move while he checked other patients. By the time he came back in, other than being irritated by the insertion it was feeling better. I am hoping this helps because I do not want to even consider surgery. I want to be able to exercise and dance without the feeling like I have to push my bladder back up. The idea that the pessary and kegals will help strengthen my muscles has really encouraged me. Thank you so much.

You’re on the right road with a good pessary fitting! I encourage you to do the Kegels with the pessary. You’ll probably get at least as good, if not better and longer lasting results, as with surgery, with much lower risk than surgery. If you ultimately do have the surgery, you’ll have a better result if you’ve been strengthening your pelvic floor with the Kegels.